Chapter 44 Management of Patients With Renal Disorders

Renal Disorders Fluid and electrolyte imbalances Most accurate indicator of fluid loss or gain in an acutely ill patient is weight

Causes of Acute Renal Failure Hypovolemia Hypotension Reduced cardiac output and heart failure Obstruction of the kidney or lower urinary tract Obstruction of renal arteries or veins

Causes of Chronic Renal Failure Diabetes mellitus Hypertension Chronic glomerulonephritis, Pyelonephritis or other infections Obstruction of urinary tract Hereditary lesions Vascular disorders Medications or toxic agents

Glomerular Diseases An inflammation of the glomerular capillaries Acute nephritic syndrome Chronic glomerulonephritis Nephrotic syndrome

Acute Nephritic Syndrome Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis Manifestations include hematuria, edema, azotemia, proteinuria, and hypertension May be mild, or may progress to acute renal failure Medical management includes supportive care and dietary modifications; treat cause if appropriate— antibiotics, corticosteroids, and immunosuppressants

Nursing Management: Acute Nephritic Syndrome Patient assessment Maintain fluid balance Fluid and dietary restrictions Patient education Follow-up care

Chronic Glomerulonephritis Causes include repeated episodes of acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage. Symptoms vary; may be asymptomatic for years, as glomerular damage increases, before signs and symptoms develop of renal insufficiency/failure. Abnormal laboratory tests include urine with fixed specific gravity, casts, and proteinuria; and electrolyte imbalances and hypoalbuminemia. Medical management is determined by symptoms.

Nursing Management Chronic Glomerulonephritis Assessment Potential fluid and electrolyte imbalances Cardiac status Neurologic status Emotional support Teaching self-care

Renal Failure Results when the kidneys cannot remove wastes or perform regulatory functions A systemic disorder that results from many different causes Acute renal failure is a reversible syndrome that results in decreased GFR and oliguria Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia

Nursing Process: The Care of the Patient with Renal Failure—Assessment Fluid status Nutritional status Patient knowledge Activity tolerance Self-esteem Potential complications

Nursing Process: The Care of the Patient with Renal Failure—Diagnoses Excess fluid volume Imbalanced nutrition Deficient knowledge Risk for situational low self-esteem

Collaborative Problems/Potential Complications Hyperkalemia Pericarditis Pericardial effusion Pericardial tamponade Hypertension Anemia Bone disease and metastatic calcifications

Nursing Process: The Care of the Patient with Renal Failure—Planning Goals may include maintaining of IBW without excess fluid, maintenance of adequate nutritional intake, increased knowledge, participation of activity within tolerance improved self-esteem, and absence of complications.

Excess Fluid Volume Assess for signs and symptoms of fluid volume excess, and keep accurate I&O and daily weights Limit fluid to prescribe amounts Identify sources of fluid Explain to patient and family the rationale for the restriction Assist patient to cope with the fluid restriction Provide or encourage frequent oral hygiene

Imbalanced Nutrition Assess nutritional status; weight changes and lab data Assess patient nutritional patterns and history; note food preferences Provide food preferences within restrictions Encourage high-quality nutritional foods while maintaining nutritional restrictions Assess and modify intake related to factors that contribute to altered nutritional intake, eg, stomatitis or anorexia Adjust medication times related to meals

Risk for Situational Low Self Esteem Assess patient and family responses to illness and treatment Assess relationships and coping patterns Encourage open discussion about changes and concerns Explore alternate ways of sexual expression Discuss role of giving and receiving love, warmth, and affection

Hemodialysis System

Hemodialysis Catheter

Internal Arteriovenous Fistula and Graft

Peritoneal Dialysis

Peritoneal Dialysis

Nursing Management of the Hospitalized Patient on Dialysis (1 of 2) Protection of vascular access; assess site for patency and signs of potential infection, and do not use for blood pressure or blood draws. Monitor fluid balance indicators and monitor IV therapy carefully; accurate I&O, IV administration pump. Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data. Monitor cardiac and respiratory status carefully. Hypertension: monitor blood pressure, antihypertensive agents must be held on dialysis days to avoid hypotension.

Nursing Management of the Hospitalized Patient on Dialysis (2 of 2) Monitor all medications and medication dosages carefully. Avoid medications containing potassium and magnesium. Address pain and discomfort. Stringent infection control measures. Dietary considerations: sodium, potassium, protein, and fluid; address individual nutritional needs. Skin care: pruritis is a common problem; keep skin clean and well moisturized, and trim nails and avoid scratching. CAPD catheter care.

Kidney Surgery Preoperative considerations Perioperative concerns Postoperative management Potential hemorrhage and shock Potential abdominal distention and paralytic ileus Potential infection Potential thromboembolism

Patient Positioning and Incisional Approaches

Renal Transplantation

Postoperative Nursing Management Assessment: include all body systems, pain, fluid and electrolyte status, and patency and adequacy of urinary drainage system Diagnoses: ineffective airway clearance, ineffective breathing pattern, acute pain, fear and anxiety, impaired urinary elimination, and risk for fluid imbalance Complications: bleeding , pneumonia, infection, and DVT

Interventions Pain relief measures and analgesic medications Promote airway clearance and effective breathing pattern by appropriate pain relief, deep breathing coughing exercises, and incentive spirometry and positioning Monitor UO and maintain potency of urinary drainage systems Use strict asepsis with catheter and appropriate technique in providing all care Monitor for signs and symptoms of bleeding Encourage leg exercises, early ambulation, and monitor for signs of DVT

Patient Teaching Instruct both patient and family Drainage system care Strategies to prevent complications Signs and symptoms Follow-up care Fluid intake Health promotion and health screening